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Shoulder pain- why you should see a physiotherapist

Part 1: Treating the most common shoulder condition- RCRSP

Shoulder pain is common. In fact, according to a recent study, it is the the 3rd most common musculoskeletal complaint given by patients when visiting their family doctors.

People with shoulder pain often choose to consult with their GP鈥檚 or an orthopedic doctor in order to treat their condition. However, in the majority of cases, a physiotherapist is the most well-equipped person to help patients with shoulder pain. Physiotherapists are able to assess, diagnosis and treat the shoulder, helping patients return to pain free activities of daily living.

Assessing patients with shoulder pain

The first thing a physiotherapist needs to establish in a patient with shoulder pain, is its cause. After some subjective questioning (and ruling out the possibility of sinister pathology), a physio will be able to tell if:

  • The cause of the shoulder pain is actually the shoulder (often pain felt in the shoulder can be referred from other structures, for example , the neck).
  • The pain is related to a stiff shoulder (frozen shoulders and arthritic shoulders fit into this category)
  • The pain is related to an unstable shoulder (dislocations and subluxation)
  • The pain is related to soft tissues of the shoulder (Rotator Cuff Related Shoulder Pain)
  • There are a combination of factors at play

The most common shoulder pathology that presents in patients with shoulder pain is number 4, Rotator Cuff Related Shoulder Pain (RCRSP). This pathology represents around 80% of all patients with shoulder pain.

RCRSP is a common term that has been coined to encompass all soft tissue injuries around the shoulder including subacromial pain, impingement syndrome, bursitis, rotator cuff tendinopathy/tears and biceps tendinopathy (ref).

Patients with RCRSP usually have at least one of the following symptoms

1) Pain around the deltoid area of the shoulder as seen in Image One. Pain may also refer up and down the arm if the condition is acute

2) Pain which is usually worse when lifting the arm to the side

3) Pain when lying on the shoulder

Image One


Objective tests confirming RCRSP

There are more than 70 special shoulder tests that have been developed to identify shoulder pathology (ref). The diagnosis of RCRSP can be done via a physiotherapist using only 3 simple tests. An example of one of these tests is called the Painful Arc test and can be performed by the patient alone (see Image Two). The painful arc test is positive if shoulder pain is reproduced when abducting the shoulder. Pain is most commonly felt between 60-120 degrees of abduction.

Image Two

Does a patients with shoulder pain need imaging

Often patients think that they need imaging for the shoulder (most commonly X-rays or ultrasound scans) to help diagnosis their problem. It is important to note, the results of imaging are often not that useful and don鈥檛 tend to change the management of the patient in most cases. A small tear or tendinopathy seen on ultrasound of a painful shoulder, can also be found on shoulders which are not painful and are part of the normal aging process. Many people who have changes or pathology on scans have no pain at all. Therefore the pain one experiences when ones shoulder hurts is not necessarily from the structural finding on the scan. These changes may have been there for years and never been a problem.

That is not to say scans are never needed. Scans can be useful to rule out any red flags (sinister conditions like cancer) or after major trauma to rule out fractures.

How does physiotherapy treat RCRSP?

A recent systematic review that analyzed the literature within the last 6 years produced a strong recommendation for exercise and manual therapy (soft tissue massage, mobilisations etc) in the treatment of RCRSP.

Load management is of vital importance when it comes to the treatment of shoulder pain. The optimal exercise regime for one persons shoulder pain will be different from another persons shoulder pain. A good physiotherapist will be able to explain exactly which loads/exercises will be good for your shoulder and which loads to avoid. It is important to note that RSCRSP injuries can take time to recover. Depending on how long the patient has had the condition, it can take up to 12 weeks of progressive rehabilitation to resolve RCRSP.

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